Health Insurance Chapter 5:Legal And Regulatory Insurance

10 Questions | By Phliproc | Last updated: Mar 20, 2022 | Total Attempts: 993

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1.

A commercial insurance company sends a letter to the physician requesting a copy of a patients entire medical record in order to process a payment. No other documents accompany the letter. The insurance specialist should?
- A.
  
  Contact the patient via telephone to alert him about the request
- B.
  
  Let the patients physician handle the situation personally
- C.
  
  Make a copy of the record and mail it to the insurance company
- D.
  
  Require a signed patient authorization letter from the insurance company
2.

An attorney calls a physicians office and requests that a copy of his clients medical record be immediately faxed to the attorneys office. The insurance specialist should?
- A.
  
  Call the HIPPA hot line number to report a breach of confidentiality
- B.
  
  Explain to the attorney that the office does not fax or copy patients records
- C.
  
  Instruct the attorney to obtain the patients signed authorization
- D.
  
  Retrieve the patients medical record and fax it to the attorney
3.

An insurance company calls the office to request information about a claim. The insurance specialist confirms the patients dates of service and the patients negative HIV status. The insurance specialist
- A.
  
  Appropriately released the dates of service but not the patients negative HIV status
- B.
  
  Breached patient confidentiality by confirming the dates of service
- C.
  
  Did not breach patient confidentiality because the patients HIV status was negative
- D.
  
  Was in compliance with HIPPA provisions concerning release of dates of service and HIV status
4.

A patients spouse comes to the office and request diagnostic and treatment information about his wife. The spouse is the primary policy holder on which his wife is named on the policy as a dependent. The insurance specialist should
- A.
  
  Allow the patients spouse to review the actual record in the office but not release a copy
- B.
  
  Inform the patients spouse that he must request the information from the insurance company
- C.
  
  Obtain a signed patient authorization from the wife before releasing patient information
- D.
  
  Release a copy of the information to the patients spouse because he is the primary policy holder
5.

Which is considered Medicare fraud?
- A.
  
  Billing for services that were not furnished and misrepresenting diagnosis to justify payment
- B.
  
  Charging excessive fees for services, equipment, or supplies provided by the physician
- C.
  
  Submitting claims for services that are not medically necessary to treat a patients condition
- D.
  
  Violating participating provider agreements with the insurance companies and government programs
6.

Which is considered Medicare abuse?
- A.
  
  Falsifying certificates of medical necessity, pans of treatment, and medical records to justify payments
- B.
  
  Improper billing practices that result in Medicare payment when the claim is legal responsibility of another third-party payer
- C.
  
  Soliciting, offering, or receiving a kickback for procedures and/or services provided to patients in the physicians office
- D.
  
  Unbundling codes;that is, reporting multiple CPT codes on a claim to increase reimbursement from a payer
7.

A patient receives services on April 5, totaling $1,000. He paid a $90 coinsurance at the time services were rendered. (The payer required the patient to pay a 20% coinsurance at the time services were provided) The physician accepted assignment, and the insurance company established the reasonable charge as $450. On July 1 the provider received $360 from the insurance company. On August 1 the patient received a check from the insurance company in the amount of $450. The overpayment was__________, and the_____________must reimburse the insurance company.
- A.
  
  $450, patient
- B.
  
  $450, physician
- C.
  
  $550, patient
- D.
  
  $640, physician
8.

The patient underwent office surgery on October 10, and the third-party payer determined the reasonable charge to be $1,000. The patient paid 20% coinsurance at the time of the office surgery, The physician and patient each received a check for $500, and the patient signed the check over to the physician. The overpayment was__________, and the_________must reimburse the insurance company
- A.
  
  $200, patient
- B.
  
  $200, physician
- C.
  
  $500, patient
- D.
  
  $500, Physician
9.

The 66 year old patient was treated in the emergency department (ED) for a fractured arm. The patient said, "I was moving a file cabinet for my boss when it tipped over and fell on my arm" The facility billed Medicare and received reimbursement of $550. The facility later determined that Medicare was not the payer because this was a workers compensation case.
- A.
  
  Is guilty of both fraud and abuse according to HIPPA because of accepting the $550
- B.
  
  Must give the $550 check to the patient, who should contact workers compensation
- C.
  
  Should have billed the employers workers compensation payer for the ED visit
- D.
  
  Was appropriately reimbursed $550 by medicare for the emergency department visit.
10.

The physician submitted a claim on which he had accepted assignment-of-benifits statement for the office. The payer determined that reasonable charge for services provided to the patient was $500 and reimbursed the physician $400. The patient paid $200 at the time services were provided. (The payer required the patient to pay a 20% coinsurance amount when services were provided.) The insurance specialist should
- A.
  
  Charge the patient an additional $100
- B.
  
  Refund the patient a $100 overpayment
- C.
  
  Return the $400 check to the payer
- D.
  
  Submit the patients name to collections